Optimizing Aetna Express Scripts Integration for Prior Authorization Workflows

Understanding Aetna's Prior Authorization Ecosystem

Aetna, a CVS Health-owned national insurer, utilizes specific channels for its prior authorization requests. Medical benefit precertification for commercial and Medicare Advantage plans primarily routes through the Availity provider portal or via X12 278 transactions for applicable procedure categories. For pharmacy benefit PA, Aetna's PBM, CVS Caremark, administers requests through ePA partners like CoverMyMeds and Surescripts for retail prescriptions, and its direct provider portal for mail-order scenarios.

Navigating Express Scripts Prior Authorization Requirements

Express Scripts, a distinct PBM under Cigna/Evernorth, manages its own set of prior authorization criteria and submission pathways for pharmacy benefits. While Aetna's pharmacy benefit is handled by CVS Caremark, providers frequently manage patients with coverage across multiple plans and PBMs. Klivira's platform is designed to manage these separate PBM workflows, including those for Express Scripts, alongside Aetna's specific medical and pharmacy PA processes.

Key Aetna Prior Authorization Channels and Criteria

• **Medical PA:** Submitted via the Availity portal or X12 278 transactions for applicable services.
• **Pharmacy PA (CVS Caremark):** Handled through CoverMyMeds or Surescripts ePA for retail, and CVS Caremark's portal for mail-order.
• **Medical Necessity Criteria:** Published in Aetna Clinical Policy Bulletins (CPBs), which are versioned and publicly available.
• **Specialty Drug PA:** Some specialty injectables and infusions are managed under the medical benefit, requiring specific workflows.
• **Inpatient Admission Notification:** Concurrent review intake procedures are documented on Aetna's precertification pages, with notification windows varying by line of business.

Streamlining Diverse Payer and PBM Workflows with Klivira

Klivira centralizes the prior authorization process by connecting to Aetna's primary submission channels, including Availity and X12 278 for medical PAs, and ePA partners like CoverMyMeds and Surescripts for pharmacy benefits managed by CVS Caremark. Simultaneously, Klivira supports integration with separate PBM systems, such as those used by Express Scripts, allowing providers to manage all PA types from a single, intuitive interface. This approach minimizes the need for staff to navigate multiple portals and disparate systems.

Addressing Turnaround Times and Compliance Considerations

Prior authorization turnaround times for Aetna are governed by state-mandated minimums and NCQA Utilization Management accreditation standards. For Aetna's Medicare Advantage, Medicaid managed-care, CHIP managed-care, and QHP-on-FFM lines of business, CMS-0057-F introduces new requirements for electronic PA API conformance and decision timeframes by 2027. Klivira's platform supports compliance by providing real-time tracking, automated alerts, and comprehensive audit trails across all managed PA requests, including those for Express Scripts.

Leveraging Klivira for Unified PA Management

Klivira offers a robust solution for managing the complexities inherent in handling both Aetna's diverse prior authorization requirements and the distinct processes of PBMs like Express Scripts. By automating submission, tracking, and documentation, Klivira reduces administrative burden, improves decision-making speed, and enhances overall revenue cycle efficiency for healthcare organizations operating across varied payer and PBM landscapes.